Demographic and psychosocial profile of smoking among pregnant women in Lebanon: public health implications

The Environmental Exposures in Lebanese Infants (EELI) birth cohort: an investigation into the Developmental Origins of Health and Diseases (DOHaD)

The EELI Study is a longitudinal birth cohort launched in 2021 in Lebanon to examine the long-term impact of environmental exposures on the health of prospective Lebanese mothers and infants and disease outcomes. This article delineates the adopted study design and protocols, current progress, and contextual considerations for the planning and launching of a birth cohort in a resource-limited setting. A sample of n = 135 pregnant women expecting to give birth at the Hôtel-Dieu de France University Hospital has been recruited since the study launch. Over 500 variables have been recorded for each participant, and over 1000 biological specimens have been processed and stored in a biobank for further analysis. The EELI study establishes methodological and logistic basis to explore the concept of the exposome and its implementation and to establish a toolkit of the SOPs and questionnaires that can be employed by the other countries in the Eastern Mediterranean region.

Waterpipe Tobacco (Hookah) Use in Pregnancy: Associations with Nausea and Vomiting of Pregnancy

OBJECTIVE

Waterpipe tobacco (WPT) use is common among reproductive age patients and is often perceived as safer than cigarette use. Prior studies have shown a decrease in nausea and vomiting symptoms among pregnant women who use cigarettes, but no studies to date have examined these symptoms in pregnant women who use WPT. This study was aimed to investigate the extent of symptoms of nausea/vomiting of pregnancy among participants who self-reported WPT use during pregnancy.

STUDY DESIGN

Secondary analysis of a prospective cohort study examining WPT use during pregnancy. Participants completed the Pregnancy-Unique Quantification of Emesis (PUQE) during first and third trimesters. Medical conditions were determined by medical record review. Participants were evaluated by sole WPT use versus dual/polysubstance WPT use and frequency of WPT use.

RESULTS

Ninety-nine (100%) participants completed the PUQE questionnaire during first trimester and 82 (82.8%) completed the PUQE during third trimester. Almost all (91.9%) participants reported moderate nausea/vomiting symptoms at both assessments. There was no difference in frequency of WPT use in pregnancy or rates of dual/polysubstance WPT use in participants with all levels of the PUQE questionnaire. There was also no difference in rates of WPT use or PUQE scores between sole WPT users and dual/polysubstance users. When comparing low and high WPT use, those who were in the higher frequency use group had higher waterpipe dependence scale scores (7.2 vs. 5.3, p < 0.02). With regard to maternal medical comorbidities, the only difference between groups was that sole WPT users were more likely to have a diagnosis of asthma than dual/polysubstance users (36.8 vs. 14.9%, p < 0.02).

CONCLUSION

There were no differences in symptoms of nausea and vomiting of pregnancy or medical conditions in pregnant women who use WPT with any frequency during pregnancy. However, sole WPT users had higher rates of asthma than dual/polysubstance WPT users.

KEY POINTS

· Waterpipe tobacco use is one of the most common forms of tobacco use among reproductive age patients.. · Waterpipe tobacco use was not associated with any changes in nausea/vomiting of pregnancy symptoms.. · Future research on the use of waterpipe tobacco in pregnancy can aid in public health responses..

Genotoxicity of waterpipe smoking in young adults from Sarajevo, Bosnia & Herzegovina

Background

Waterpipe, also known as a hookah or narghile, is a type of tobacco products consumption device. Recently it has been increasingly popular in Bosnia and Herzegovina and the region. Waterpipe consumers are predominantly adolescents and young adults. Many of them believe in slighter harmful effects of waterpipes, compared to cigarettes. We aimed to determine the DNA damage in oral leukocytes and buccal cells of young individuals who have smoked a waterpipe for more than one year.

Methods

The study group consisted of 40 cigarette non-smokers who regularly smoked a waterpipe on average of once per week. As a control, 40 non-smoking individuals were selected to match smokers for age. All participants in the study were healthy male and female adults from Bosnia and Herzegovina, 18-30 years of age. Before sampling, detailed survey and informed consent have been provided by each participant. Comet assay in oral leukocytes and buccal micronucleus cytome (BMCyt) assay in exfoliated buccal cells were applied.

Results

Almost half of waterpipe smokers (WPS) tasted waterpipe at 15-16 years of age. Comet assay analysis showed increased tail intensity, tail length, and tail moment values among WPS compared to non-smokers (NS) (p = 0.0001, p = 0.0067, and p = 0.0001, respectively). Frequencies of the micronucleated (p = 0.0004), binucleated (p = 0.01), karyorrhectic, (p = 0.0036), and pycnotic cells (p = 0.03) were significantly higher in WPS compared to NS group.

Conclusions

Genotoxicity and DNA damage biomarkers were increased in oral leukocytes and exfoliated buccal cells of young waterpipe smokers from Bosnia and Herzegovina, compared to NS group.

Dietary Reference Intake of n-3 polyunsaturated fatty acids for Koreans

This paper examines the process and evidence used to create the Dietary Reference Intake (DRI) of alpha-linolenic acid (ALA) and eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) for Koreans. ALA (18:3n3) is an essential fatty acid, and EPA and DHA are known to have beneficial effects on cardiovascular disease risk and reduction of triglyceride levels. Various international organizations have suggested dietary recommendations for n-3 polyunsaturated fatty acids (PUFAs), including ALA, EPA, and DHA. A DRI for Koreans was established for the first time in 2020, specifically for the adequate intake (AI) of ALA and EPA + DHA. This recommendation was based on the average intake of ALA and EPA + DHA from the Korea National Health and Nutrition Examination Survey 2013–2017. For Korean infants, the AI of ALA and DHA was based on the fatty acid composition of maternal milk. Estimated average requirement and a tolerable upper intake level have not been set for n-3 PUFA due to insufficient evidence. In addition, the intake level of n-3 PUFA for prevention of chronic disease has also not been determined. Future studies and randomized controlled trials are required to establish the UL and to define the level for disease prevention.

Exclusive and Dual Cigarette and Hookah Smoking Is Associated with Adverse Perinatal Outcomes among Pregnant Women in Cairo, Egypt

This study assessed the prevalence of prenatal smoking, factors associated with prenatal smoking, and its association with birth outcomes in a sample of pregnant women in Egypt. Pregnant women were recruited during their last trimester from antenatal clinics in Cairo from June 2015 to May 2016. Participants completed an interviewer-administered survey that assessed tobacco use and attitudes, and exhaled carbon monoxide (CO) was measured. Gestational age at delivery and offspring birth weight were collected via a postnatal phone interview. Two hundred pregnant women ages 16–37 years participated. More than a quarter (29.0%) of women reported smoking (cigarettes, hookah, or both) during their current pregnancy, and hookah was more popular than cigarettes. Most women who smoked prior to their current pregnancy either maintained their current smoking habits (46.6%) or switched from dual to hookah-only smoking (46.6%). Current smokers during pregnancy had a higher mean (±SD) exhaled CO level (2.97 ± 1.45 vs. 0.25 ± 0.60 ppm, p < 0.001) and had babies with a lower mean birth weight (2583 ± 300 vs. 2991 ± 478 g, p < 0.001) than non-smokers. Smokers during pregnancy had greater odds of premature birth and/or low birth weight babies compared to non-smokers. Dual cigarette-hookah smokers had the highest risk. Additional focused programs are required to prevent women of childbearing age from initiating tobacco use and empower women to stop tobacco use during the preconception and gestational periods.

Health-Related Behaviors of Pregnant Women Residing in Urban and Rural Areas in Poland

The aim of this study was to evaluate the knowledge regarding a healthy lifestyle and prophylaxis during pregnancy among women from rural and urban areas and how this changed within a 5-year period. Analyses of the population of pregnant women in Poland were made using a questionnaire survey. The survey was conducted in the years 2010-2012 and 2017. Questionnaires from 6128 pregnant women were collected. The statistical analyses were conducted using IBM SPSS. The examined population was comprised of 41% women from rural areas and 59% women from urban areas. Alcohol consumption was lower among women from rural areas than among urban inhabitants in 2010-2012; in 2017 a trend of even lower consumption was observed. Folic acid supplementation was more broadly developed in the urban population; however, in 2017, higher percentage rates of both populations admitted taking folates before pregnancy. More women in urban than in rural areas performed physical activity during pregnancy, but the differences decreased in 2017. Knowledge of a healthy lifestyle and prophylaxis during pregnancy increased regardless of place of residence; however, the most evident change could be observed among women from rural areas.

Comparing cigarette smoking knowledge and attitudes among smokers and non-smokers

Smoking prevalence in Lebanon was reported by the World Health Organization to be 43%, which is among the highest rates in the Arab nation. The objectives of this study were to assess cigarette smoking knowledge and attitude among smokers and non-smokers using validated scales in the Lebanese general population and evaluate their association with current cigarette smoking; a secondary objective is to assess the dose effect relationship of knowledge and attitude with cumulative smoking. This cross-sectional took place between May and December 2018, and enrolled a sample of 2623 participants, representative from all Lebanese governorates. A questionnaire about knowledge of the harmful effects of tobacco and attitude toward smoking bans retrieved from other studies was used to collect data. Male gender (ORa = 0.75), having a low monthly income (ORa = 1.56) and a higher passive smoking score (ORa = 1.25), were significantly associated with higher odds of being current smokers. Higher knowledge score (ORa = 0.97) and positive attitude toward smoking ban score (ORa = 0.94) were significantly associated with lower odds of being current smokers. In addition, increased age (ß = 15.21) and higher passive smoking score (ß = 26.58) were significantly associated with higher cumulative cigarette smoking. More positive attitude toward smoking ban score (ß = - 6.51) and having a university degree (ß = - 68.35) were significantly associated with lower cumulative cigarette smoking. Higher knowledge about the smoking-related health problems and better attitudes toward smoking ban were observed among non-smokers compared to smokers. It is important to increase awareness campaigns and to propose effective interventions to put in place an adequate culture of smoking cessation among the general population.

Waterpipe (hookah) tobacco use in pregnancy: use, preferences and perceptions of flavours

OBJECTIVE

Waterpipe tobacco (WPT; hookah) use is common in pregnant and reproductive-age women. Sweet flavours contribute to the appeal of WPT and are a potential regulatory target. This study investigated use, preferences and perceptions of WPT flavours in pregnant WPT users, and the impact of flavour preferences on preconception/prenatal WPT use and exposure biomarkers.

METHODS

58 pregnant WPT users (mean age=27 years) completed a detailed interview regarding their WPT flavours use, preferences and perceptions. Biomarkers of nicotine and carcinogen exposure (eg, cotinine, benzene, butadiene) were also collected.

RESULTS

55% of participants were dual/poly WPT users (ie, reported use of one or more other tobacco products in addition to WPT). Pregnant WPT users reported nearly exclusive use of flavoured WPT, with greater use of menthol/mint (68%) followed by fruit flavours (48%) (p<0.001), and greater preferences for fruit followed by menthol/mint flavours (ps<0.05). Harm perceptions did not differ among flavours. Compared with dual/poly WPT users, WPT-only users reported more total WPT use events, greater use of and preference for menthol/mint flavoured WPT (ps<0.001), and decreased exposure biomarkers (ps≤0.040). Preference for menthol/mint and fruit flavours predicted more flavoured WPT use events during preconception and pregnancy; preference for menthol/mint predicted detectable cotinine and benzene levels but not butadiene.

CONCLUSIONS

This is the first study of WPT flavour use, preferences and perceptions in pregnant women. Use of and preference for menthol/mint and fruit WPT flavours in this vulnerable population could be considered in regulating WPT flavours to protect the health of women and children.

Effect of waterpipe tobacco smoke exposure during lactation on learning and memory of offspring rats: Role of oxidative stress

AIMS

The prevalence of waterpipe tobacco smoking is increasing among breastfeeding women. Herein, the effect of maternal waterpipe tobacco smoke (WTS) exposure during lactation on learning and memory of adult offspring rats was examined.

MAIN METHODS

Lactating rats received either fresh air or mainstream WTS (1 h twice daily) from day 4 to day 21. Learning and memory was examined by the radial arm water maze and the levels of brain derived neurotrophic factor (BDNF) and oxidative stress biomarkers superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase and thiobarbituric acid reactive substances (TBARS) were assessed in the hippocampus of adult male offspring rats.

KEY FINDINGS

Maternal exposure to WTS during lactation impaired the long-term memory and reduced levels of BDNF (P < 0.05) in hippocampus in adult male offspring rats. The activity of SOD, GPx and catalase were reduced (P < 0.05) while level of TBARS was increased (P < 0.05).

SIGNIFICANCE

Maternal WTS exposure during lactation impaired the long-term memory of adult male offspring that was associated with low levels of BDNF and altered oxidative stress balance. Therefore, careful measures should be taken to enhance waterpipe smoking cessation during breastfeeding.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

Cigarette smoking in a Middle Eastern country and its association with hospitalisation use: a nationwide cross-sectional study

OBJECTIVES

Little is known about the distribution of cigarette smoking by place and persons at the national level or its burden on healthcare expenditure in countries of the Middle East. We examine in this study the pattern of cigarette smoking by age, gender and geography and assess its association with hospitalisation use in Lebanon, a small middle-income country in the Middle East.

DESIGN

Population-based cross-sectional study.

SETTING

The study draws on data collected as part of the nationwide multistage cluster sample Nutrition and Non-Communicable Disease Risk Factor survey conducted in Lebanon in 2009.

PARTICIPANTS

A total of 2836 Lebanese adults 18 years and over.

MEASURES

Hospitalisation, the outcome variable, was measured using one item and recoded as a dichotomous variable. Cigarette smoking, the main exposure variable, was assessed by examining smoking status and pack-years, capturing intensity, frequency and duration of exposure.

RESULTS

The overall prevalence rate of current smoking in this study was 34.7%, with significantly higher rates in males than females (42.9% and 27.5%, respectively). Close to two-thirds of the study population reported ever being hospitalised (62.8%). Compared to non-smokers, past and current smokers were significantly more likely to be hospitalised, after controlling for sociodemographic and health-related characteristics (OR=2.9, 95% CI 1.26 to 3.34, and OR=1.35, 95% CI 1.12 to 1.63, respectively). Hospitalisation use increased significantly in a dose-response manner with increasing pack-years.

CONCLUSIONS

When compared to regional and international estimates, the prevalence rates of smoking in Lebanon are considerably high, with percentages among women being among the highest in the region. Our findings of increased odds of hospitalisation among ever smokers, net of the effect of comorbidity, underscore the additional burden of smoking on the healthcare bill cost. Continued monitoring of smoking rates and disease surveillance frameworks are warranted in developing countries for policy development and evaluation.

Analytical Determination of Vitamin B12 Content in Infant and Toddler Milk Formulas by Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS)

The development of a sample preparation method and optimization of the analytical instrumentation conditions were performed for the determination of the vitamin B₁₂ content in emulsified baby foods sold on the Korea market. After removal of the milk protein and fats by chloroform extraction and centrifugation, the vitamin B₁₂ was water extracted from the sample. Following filtration of the solution through a nylon filter, the water-soluble extract was purified by solid-phase extraction using a Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS). The solution eluted from the cartridge was dried under a stream of nitrogen gas and reconstituted with 1 mL of water. The sample solution was injected into an LC-MS/MS system after optimizing the mobile phase for vitamin B₁₂ detection. The calibration curve showed good linearity with the coefficient of correlation (r²) value of 0.9999. The limit of detection was 0.03 µg/L and the limit of quantitation was 0.1 µg/L. The method of detection limit was 0.02 µg/kg. The vitamin B₁₂ recovery from a spiking test was 99.62% for infant formula and 99.46% for cereal-based baby food. The sample preparation method developed in this study would be appropriate for the rapid determination of the vitamin B₁₂ content in infant formula and baby foods with emulsified milk characteristics. The ability to obtain stable results more quickly and efficiently would also allow governments to exercise a more extensive quality control inspection and monitoring of products expected to contain vitamin B₁₂. This method could be implemented in laboratories that require time and labor saving.

Malocclusion in elementary school children in beirut: severity and related social/behavioral factors

Aim. To assess severity of malocclusion in Lebanese elementary school children and the relationship between components of malocclusion and sociodemographic and behavioral factors. Methods. Dental screening was performed on 655 school children aged 6-11 from 2 public (PB) and 5 private (PV) schools in Beirut. A calibrated examiner recorded occlusion, overjet, overbite, posterior crossbite, midline diastema, and crowding. Another examiner determined the DMFT (Decayed/Missing/Filled Teeth) score. A questionnaire filled by the parents provided data on sociodemographic and behavioral factors. Multinomial, binomial, and multiple linear regressions tested the association of these factors with occlusal indices. Results. Malocclusion was more severe in PB students. Age and sucking habit were associated with various components of malocclusion. Crowding was more prevalent among males and significantly associated with the DMFT score. Income and educational level were significantly higher (P < 0.05) in PV pupils and deleterious habits were more frequent in PB children. Conclusions. Children of lower socioeconomic background had more severe malocclusions and poorer general dental health. Compared to Western and WHO norms, the findings prompt health policy suggestions to improve dental care of particularly public school children through regular screenings in schools, prevention methods when applicable, and cost effective practices through public and private enabling agencies.

Women's attitude toward smoking: effect of a community-based intervention on smoking-related social norms

BACKGROUND

Smoking has long been discouraged in Iranian women. However, in recent years, more women have started smoking. This study aimed to investigate the role of women's attitude towards smoking on smoking prevalence in women in the context of a community-based intervention program.

METHODS

Participants were samples of the third and fifth evaluation stages of the 'Isfahan Healthy Heart Program', which is a comprehensive community-based intervention program for noncommunicable disease prevention and control. A total of 3112 and 4794 women were investigated in 2004 and 2007, respectively. Intervention and reference groups were assessed for smoking habits and attitude towards smoking. T test and chi-square test were used to compare the parameters between the intervention and the reference groups.

RESULTS

Negative attitude towards smoking increased significantly in the intervention and the reference groups from 2004 to 2007 (P = 0.0001). Negative attitude towards smoking in women decreased significantly in the intervention group (P = 0.0001), whereas it increased significantly in the reference group (P = 0.0001). However, smoking prevalence showed a significant decrease in women in the intervention group, from 2.5 to 1% (P < 0.0001) and a nonsignificant decrease in the reference group.

CONCLUSION

A change in social norms towards acceptability of smoking for women can be overcome by effective strategies that discourage the population from smoking.

Improving awareness of preconception health among adolescents: experience of a school-based intervention in Lebanon

BACKGROUND

Maternal behavior before and after conception affects maternal and child health. Limited awareness of adolescents in preconception health may be addressed through school education. The aim of this intervention is to assess preconception health awareness among adolescents in Lebanese high schools and to test the effectiveness of a one-time educational session in improving preconception knowledge.

METHODS

The intervention consisted of a 30-minute educational session about good practices in preconception health, developed by the National Collaborative Perinatal Neonatal Network's (NCPNN) research team. A convenience sample of high school Lebanese students in grades 10 to 12, aged 14 to 26 years old, from 70 private and public schools in all six Lebanese provinces, participated in the intervention in 2011 and 2012. A multiple-choice questionnaire administered prior to and 2 months after the session was used to assess knowledge improvement among the students.

RESULTS

A total of 7,290 students were enrolled. After the session, mean scores of correct answers increased from 4.36 to 6.42 out of 10, representing a 47.2% improvement (p < 0.001). The percent of correct answers increased for all the questions regarding health practices (p < 0.001). The greatest improvement was observed for questions about Trisomy 21, folic acid intake and toxoplasmosis with percentages improvement of 96%, 172% and 83% respectively. Being female or in private school was a significant predictor of higher scores in both pre-test and post-test (p < 0.001).

CONCLUSIONS

Awareness campaigns in schools increased the preconception health knowledge among high school students. We recommend expanding the scope of this intervention into universities in Lebanon.

The many faces of tobacco use among women

Smoking is still considered to be mainly a male problem. However, it is estimated that there are approximately 250 million women worldwide who smoke cigarettes and millions more women who use smokeless tobacco products. This article addresses the many facets of tobacco use among women. The aim of the paper is to increase recognition among clinicians and researchers of the specific characteristics of female tobacco use. Together with providing epidemiological data on the distribution of tobacco use among women and data from population-based analyses on sociocultural factors that influence it, the article presents tobacco use during pregnancy as a particularly important public health problem. Further, the article points out sex-related differences (ie, physiological, psychological, or behavioral) between male and female tobacco use. A special focus is on the important role of ovarian hormones. Adverse effects of tobacco use to women and their children as well as tobacco-related morbidities and comorbidities are presented, and women's greater susceptibility to tobacco constituents as compared to men is stressed. Awareness of these differences can contribute to improvement of the effectiveness of smoking cessation programs addressed both to the specific female population and to an individual smoking woman.

The independent effects of second hand smoke exposure and maternal body mass index on the anthropometric measurements of the newborn

Background

Exposure to tobacco smoke during pregnancy, whether as active smoking or by exposure to secondhand smoke (SHS), is associated with adverse pregnancy outcomes including low birth weight (LBW) and small for gestational age infants due to the effect of tobacco on the anthropometric measurements of the newborn. This effect might be masked by maternal obesity as it increases fetal weight. The objectives of this study were to estimate the independent effects of maternal exposure to SHS and maternal body mass index (BMI) on the anthropometric measurements and on the prevalence of macrosomia and LBW among term infants.

Methods

Data were collected from women in the postnatal ward following delivery. Participants were stratified into six groups based on the BMI (underweight <18 kg/m², non-obese 18–29.9 kg/m², and obese ≥30 kg/m²) and the SHS exposure status (exposed and non- exposed), to examine the independent effects of BMI and SHS on infants’ anthropometry. Multiple regression analysis was used to explore the independent associations between the six groups and the risk of delivering a macrosomic or LBW infant.

Results

Infants of women exposed to SHS had significantly reduced anthropometric measurements compared to infants of unexposed women. The odds of delivering a macrosomic baby increased to 9-fold for women with BMI of ≥30 kg/m² compared to non-obese women; odds ratio (OR) 9.18, 95% Confidence Interval (CI) (1.01, 9.37); p = 0.04, this risk was attenuated to 1.5-fold in women exposed to SHS, OR 1.53, 95% CI (1.19, 12.1); p < 0.0001. The odds of delivering an LBW infant were more than doubled in underweight women compared to non-obese women, OR 2.15, 95% CI (1.001, 4.57); p = 0.034, and were further increased to almost 3-fold for women who were exposed to SHS, OR 2.71, 95% CI (1.82,4.045); p = 0.02.

Conclusion

Exposure to SHS was associated with reduced anthropometric measurements of the newborn and increased rate of LBW infants, irrespective of maternal BMI. Maternal obesity was associated with increased risk of delivering a macrosomic infant; conversely maternal underweight was associated with increased risk of delivering an LBW infant.

Social norms and attitudes linked to waterpipe use in the Eastern Mediterranean Region

Waterpipe tobacco smoking (WTS) is on the rise globally, particularly among vulnerable populations such as youth and women. Increasing knowledge about toxicant yield from waterpipe tobacco and deleterious health effects points to the potential for a health epidemic. WTS is often viewed as a safe alternative to cigarette smoking. Though the original objective of the research was to explore the social norms and attitudes that lead to waterpipe being a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean Region, the use of a qualitative research methodology resulted in rich data that helped to understand more generally the phenomenon of waterpipe smoking. Both focus group discussions (FGDs) and key informant interviews were used. Participants were recruited to represent genders, various age groups, socioeconomic status, waterpipe smoking status, and residents of urban and rural areas. A total of 81 FGDs and 38 in-depth interviews were conducted in 2007. Thematic analysis was used to analyze the transcripts. A total of ten themes emerged: socio-cultural norms, gender differences, motivation to smoke, sensory characteristics of waterpipe, metaphors, consumerism, indicators of dependence, comparison between cigarettes and waterpipe, health effect of smoking, and intervention. Results indicated that WTS has socio-cultural dynamics associated with it that are far more pronounced than health considerations. An increased socio-cultural acceptability, the perceived reduced harm and the advent of the fruity Moassel tobacco are among the many reasons for WTS acceptability. Findings point to the need for a unified strategy to address this health issue at all levels of the ecological framework and have important implications for future policy and practice.

Smoking habits in the Middle East and North Africa: results of the BREATHE study

Few recent comparative data exist on smoking habits in the Middle East and North Africa (MENA) region. The objective of this analysis was to evaluate smoking patterns in a large general population sample of individuals aged ≥ 40 years in ten countries in the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was generated and called. This identified 65,154 eligible subjects, of whom 62,086 agreed to participate. A screening questionnaire was administered to each participant, which included six questions relating to cigarette consumption and waterpipe use. The age- and gender-adjusted proportion of respondents reporting current or past smoking of cigarettes or waterpipes was 31.2% [95% CI: 30.9-31.6%]. This proportion was significantly higher (p < 0.001) in men (48.0%) than in women (13.8%), but no relevant differences were observed between age groups. Smoking rates were in general lowest in the Maghreb countries and Pakistan and highest in the Eastern Mediterranean countries, ranging from 15.3% in Morocco to 53.9% in Lebanon. Consumption rates were 28.8% [28.4-29.2%] for cigarette smoking and 3.5% [3.4-3.6%] for waterpipe use. Use of waterpipes was most frequent in Saudi Arabia (8.5% of respondents) but remained low in the Maghreb countries (< 1.5%). Cumulative cigarette exposure was high, with a mean number of pack · years smoked of 18.5 ± 20.5 for women and 29.1 ± 26.2 for men. In conclusion, smoking is a major health issue in the MENA region.

Effects of secondhand smoke on the birth weight of term infants and the demographic profile of Saudi exposed women

BACKGROUND

Maternal exposure to tobacco smoke during pregnancy is associated with detrimental effects on the mother and the fetus including; impaired fetal growth, low birth weight and preterm delivery. In utero exposure to tobacco is implicated in the etiology of many adults' diseases including obesity, diabetes and hypertension.The objectives of this study were to evaluate the effects of Secondhand Tobacco Smoke (SHS) exposure on newborns' anthropometric measurements and to compare the demographic profile of the women exposed to SHS to those who were not.

METHOD

This is a retrospective cohort study investigating the effects of SHS during pregnancy on newborns' anthropometry. Women who self-reported SHS exposure were compared with those not exposed. The primary outcomes were birth weight, newborn length and head circumference. Univariate analysis and multivariate regression analysis were performed. Adjusted differences with 95% confidence intervals were calculated.

RESULTS

Mothers exposed to SHS constituted 31% of the cohort. The mean birth weight of infants of exposed mothers was significantly lower by 35 g, 95% CI: 2-68 g, (P = 0.037) and the mean length was shorter by 0.261 cm, 95% CI 0.058-0.464 cm, (P = 0.012) compared to the infants of unexposed mothers. Women exposed to SHS, were younger, of lower parity and more likely to be illiterate than those who were not exposed in addition, exposed women were less likely to be primiparous.

CONCLUSION

The prevalence of exposure of Saudi pregnant women to SHS is high at 31% and it is associated with reduced birth weight, and shorter length of the newborn.

Long-term maintenance of smoking cessation in pregnancy: an analysis of the birth cohort generation XXI

INTRODUCTION

Pregnancy affords opportunities for health promotion and disease prevention. We worked with a population-based cohort of women who gave birth in Portugal to quantify the proportion of women who quit smoking during pregnancy, the proportion of these women who continued to abstain 4 years after delivery, and the determinants of these outcomes.

METHODS

A birth cohort was assembled in public maternity units of Porto, Portugal, in 2005-2006, and all women were reevaluated at an average of 4 years after delivery. A total of 5,420 mothers were included in the analysis. Smoking status at baseline and at follow-up was ascertained by interview. Adjusted prevalence ratios and 95% CIs were computed using robust Poisson regression.

RESULTS

Overall, 47.4% of women who smoked ceased smoking and 41.7% reduced cigarette consumption during pregnancy. Four years after delivery, 32.1% of those who stopped smoking during pregnancy continued to abstain. Older women, first-time mothers, light smokers, those who were living with a partner at the time of follow-up, those who became pregnant again after the index pregnancy, those who breast fed for more than 52 weeks, and those with a child diagnosed with asthma and/or rhinitis were more likely to abstain from smoking.

CONCLUSIONS

Approximately half of all women stopped smoking during pregnancy and, among these, approximately one third continued to abstain 4 years after delivery. The high proportion of relapse may be attributable to poor awareness or skepticism regarding the adverse effects of secondhand smoke on children or physiological and psychological dependence on nicotine.

Exposure of pregnant women to waterpipe and cigarette smoke

INTRODUCTION

Throughout the Eastern Mediterranean region, tobacco is used primarily in 2 forms: cigarette smoking and waterpipe smoking. Despite the fact that tobacco use is considered as a global public health threat, waterpipe smoking is reported to be growing in popularity, particularly among women. The objectives of this study are to determine the prevalence and patterns of cigarette, waterpipe, and passive smoking among pregnant women in Jordan, and to assess their perception of harmful effects of cigarette and waterpipe smoking.

METHODS

A total of 500 pregnant women were randomly recruited from maternity clinics in North and Middle of Jordan and surveyed regarding exposure to waterpipe tobacco and cigarette smoking.

RESULTS

The results showed that 7.9% of women were current cigarette smokers and 8.7% were current waterpipe smokers. About 82.4% of all women reported that they are exposed to cigarette smoke and 32.8% reported that they are exposed to waterpipe smoke. The most common place where women are exposed to cigarette and waterpipe smoke was their house (50.4% and 48.7%, respectively) followed by public places (31.4% and 21.4%, respectively). In addition, the husband was the main source for exposure to cigarette and waterpipe smoke (48.5% and 42.7%, respectively). Approximately, 74% of women believed that cigarette smoking is addictive, whereas only 55.1% reported that waterpipe smoking leads to addiction.

CONCLUSIONS

Exposure of pregnant women to tobacco smoke is a public health problem in Jordan that requires immediate action.

Social norms of cigarette and hookah smokers in Iranian universities

BACKGROUND

First experiences of tobacco use usually occur in adolescence. The recognition of social norms leading to youth smoking is hence necessary. We tried to assess the social norms among Iranian young cigarette and hookah smokers.

METHODS

This cross-sectional study was conducted on 451 girls and 361 boys aging 20-25 years old who entered Isfahan and Kashan Universities (Iran) in 2007. Demographic factors (age, gender, and age at smoking onset) cigarette and hookah smoking status, having a smoking father or smoking friends and four related social norms were recorded. Binary logistic regression analysis was used to separately determine associations between hookah and cigarette smoking and the four social norm variables.

RESULTS

CIGARETTE AND HOOKAH SMOKERS HAD SIGNIFICANT DIFFERENCES WITH NONSMOKERS IN TWO SOCIAL NORMS: "Perceived smoking by important characters" [odds ratio (OR) = 1.35 in cigarette smokers and 1.58 in hookah smokers; P < 0.001] and "smoking makes gatherings friendly" (OR = 3.62 in cigarette smokers and 6.16 in hookah smokers; P < 0.001). Furthermore, cigarette and hookah smoking were significantly associated with having smoking friends.

CONCLUSION

Highlighting the social norms leading to cigarette and hookah smoking may help policy makers develop comprehensive interventions to prevent smoking among adolescents.

The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review

BACKGROUND

The objective of this study was to systematically review the medical literature for the prevalence of waterpipe tobacco use among the general and specific populations.

METHODS

We electronically searched MEDLINE, EMBASE, and the ISI the Web of Science. We selected studies using a two-stage duplicate and independent screening process. We included cohort studies and cross sectional studies assessing the prevalence of use of waterpipe in either the general population or a specific population of interest. Two reviewers used a standardized and pilot tested form to collect data from each eligible study using a duplicate and independent screening process. We stratified the data analysis by country and by age group. The study was not restricted to a specific context.

RESULTS

Of a total of 38 studies, only 4 were national surveys; the rest assessed specific populations. The highest prevalence of current waterpipe smoking was among school students across countries: the United States, especially among Arab Americans (12%-15%) the Arabic Gulf region (9%-16%), Estonia (21%), and Lebanon (25%). Similarly, the prevalence of current waterpipe smoking among university students was high in the Arabic Gulf region (6%), the United Kingdom (8%), the United States (10%), Syria (15%), Lebanon (28%), and Pakistan (33%). The prevalence of current waterpipe smoking among adults was the following: Pakistan (6%), Arabic Gulf region (4%-12%), Australia (11% in Arab speaking adults), Syria (9%-12%), and Lebanon (15%). Group waterpipe smoking was high in Lebanon (5%), and Egypt (11%-15%). In Lebanon, 5%-6% pregnant women reported smoking waterpipe during pregnancy. The studies were all cross-sectional and varied by how they reported waterpipe smoking.

CONCLUSION

While very few national surveys have been conducted, the prevalence of waterpipe smoking appears to be alarmingly high among school students and university students in Middle Eastern countries and among groups of Middle Eastern descent in Western countries.

Socio-demographic factors and processes associated with stages of change for smoking cessation in pregnant versus non-pregnant women

Background

The tobacco control community assumes that the most effective interventions are personalized. Nevertheless, little attention is paid to understanding differences between pregnant and non-pregnant European women in terms of the social factors that influence tobacco use and the processes of change used to quit smoking.

Methods

The study consecutively enrolled 177 pregnant women who acknowledged smoking the year before pregnancy and 177 non-pregnant women who acknowledged smoking the year before their clinic visit for a Pap test.

Results

With respect to socio-demographic factors, the stages of change in pregnant women were associated with level of education, marital status, and the presence of roommates, partners and friends who smoke. In pregnant women, there was no statistically significant difference in the processes used to stop smoking among the stages of change. Furthermore, behavioral processes were higher in non-pregnant women than in pregnant women, and the difference was statistically significant in the advanced stages of behavioral change. Both pregnant and non-pregnant women showed higher levels of acceptance towards smoking in the earlier stages of change, but the acceptability of smoking in the pre-contemplative stage was higher in non-pregnant women. Greater craving was detected in non-pregnant vs. pregnant women at all stages and reached a statistically significant level at the pre-contemplative stage.

Conclusion

Pregnancy is a favorable time to stop smoking since pregnant women are more likely to be in an advanced stage of behavioral change. Pregnant and non-pregnant women are distinct populations in the types and processes of change involved in smoking cessation. The intervention programs to promote smoking cessation and prevent relapses will need to take these differences into account.

Determining responsibility for smoking in society: accountability continuum for Jordanian college students and its implication on FCTC implementation

As one of the first countries to ratify the WHO Framework Convention on Tobacco Control, Jordan has signaled an interest in stronger anti-tobacco restrictions. This study examines whether Jordanian students believe smoking is an individual right or a social issue, and if they would support more stringent policies and enforcement. Undergraduate Jordanian students (n = 1211) from public and private universities completed the survey. Never smokers scored significantly higher on smoking being a social issue that required public policy response (p-value < .001); whereas smokers scored significantly higher with all individual right items. Ample opportunity exists for developing and enforcing stronger tobacco policies both on college campus and generally in the country. However, increasing tobacco taxes may need to be preceded by health communication campaigns that increase knowledge of the effectiveness of the tobacco tax in reducing use and resultant premature deaths.

Factors associated with active smoking, quitting, and secondhand smoke exposure among pregnant women in Greece

Background

Pregnant women are exposed to tobacco smoke through active smoking and contact with secondhand smoke (SHS), and these exposures have a significant impact on public health. We investigated the factors that mediate active smoking, successful quitting, and SHS exposure among pregnant women in Crete, Greece.

Methods

Using a cotinine-validated questionnaire, data were collected on active smoking and exposure to secondhand smoke from 1291 women who had successfully completed the first contact questionnaire of the prospective mother-child cohort (Rhea) in Crete during the 12th week of pregnancy.

Results

Active smoking at some time during pregnancy was reported by 36% of respondents, and 17% were current smokers at week 12 of gestation. Those less likely to quit smoking during pregnancy were those married to a smoker (OR, 1.76; P = 0.008), those who were multiparous (1.72; P = 0.011), and those with young husbands. Of the 832 (64%) nonsmokers, almost all (94%, n = 780) were exposed to SHS, with the majority exposed at home (72%) or in a public place (64%). Less educated women and younger women were exposed more often than their better educated and older peers (P < 0.001). Adjusting for potential confounders, parental level of education, age, and ethnicity were the main mediators of exposure to SHS during pregnancy.

Conclusions

Active smoking and exposure to SHS are very prevalent among pregnant women in Greece. The above findings indicate the need for support of population-based educational interventions aimed at smoking cessation in both parents, as well as of the importance of establishing smoke-free environments in both private and public places.

Determinants of change in paternal smoking trends during pregnancy in Lebanon

For pregnant women and their fetus, secondhand smoking poses major public health effects. This study analyzes the determinants of change in smoking behavior among fathers whose partners were pregnant. The study is a secondary analysis of a nationally representative Lebanese cross-sectional survey of 1,028 households conducted in 2007. Currently smoking fathers with a child of 5 years of age or less were included. The main outcome was the change in the father's smoking behavior during his wife's last pregnancy. The study concluded that fathers who changed their smoking patterns when their wives were pregnant were significantly more educated, more likely to smoke a lesser number of cigarettes per day (OR = 96, 95% CI (0.93, 0.99)), and more knowledgeable about cigarette constitutes and its health risks (OR = 1.37, 95% CI (1.08, 1.74). Public health practitioners and health professionals are recommended to raise awareness and provide cessation programs for parents and especially fathers.

Breast cancer in Lebanon: incidence and comparison to regional and Western countries

BACKGROUND

Review and analyses of the 2004 Lebanese National Breast Cancer Registry (the most recently available complete national data).

METHODS

Crude, age-standardized rates (ASRs), and age-specific rates per 100,000 population were calculated and results were compared with estimates from Western, regional, and Arab countries.

RESULTS

Breast cancer constituted about 38.2% of all cancer cases among Lebanese females in the year 2004. The median age at diagnosis was 52.5 years. The age-standardized incidence rate per 100,000 was estimated at 71.0. ASRs remained lower than those observed in developed countries and in the Israeli Jewish population; however, they were greater than those estimated for Arab populations in the region. Five-year age-specific rates among Lebanese women were among the highest observed worldwide for the age groups 35-39, 40-44 and 45-49 years, with the exception of Israeli Jews for the age groups 35-39.

CONCLUSIONS

Results endorse the new guidelines developed by the Lebanese Ministry of Public Health to start breast cancer screening with mammography at 40 years of age. Further efforts are needed from different stakeholders in order to realize a comprehensive and full database, and to enhance awareness for early detection at all age groups.

Smoking cessation during pregnancy: a systematic literature review

ISSUES

Second-hand smoke presents a health risk for a large group of entirely helpless nonsmokers: unborn children. Reliable data on women continuing to smoke during pregnancy are essential for effective preventive and interventional programs. The aim of this review is therefore to identify this risk group compared with spontaneous quitters of smoking.

APPROACH

This systematic literature review is based solely on empirical original papers derived from samples of pregnant women smoking at the beginning of pregnancy. In accordance with the QUOROM Statement all population or clinic-based samples were included. Collectives from intervention studies were not included. All studies were from developed nations and published between January 1997 and March 2008.

KEY FINDINGS

A total of 19 studies were identified. The rate of quitters was between 4.0% and 69.7% for population-based studies, and 26.5% and 47.0% for clinic-based studies. A smoking partner, a large number of children, a high rate of tobacco consumption, as well as deficiencies in prenatal care were predictors of smoking during pregnancy.

IMPLICATIONS

This study identifies risk factors and correlates and indicates common obstacles for women to quit smoking during pregnancy.

CONCLUSION

The risk groups that can be defined based on our results are a key target population for preventive measures.

Arab Americans' acculturation and tobacco smoking

Limited information is available about Arab Americans' smoking behaviors. The aim of this study was to describe Arab Americans' smoking behaviors and any relationship between tobacco dependence and acculturation. This was a cross-sectional study. Arab American smokers and ex-smokers (N = 96) participated in the study. Nicotine dependence, acculturation, and tobacco use questionnaires were used to measure the major variables. Analyses revealed a significant positive correlation between acculturation and tobacco dependence and between tobacco exposure and tobacco dependence. Arab Americans who behaved most like their ethnic peers and spent more time with Arab Americans were more dependent on nicotine.

Smoking behavior in pregnant Arab Americans

OBJECTIVES

To determine the smoking behavior in pregnant Arab American women who attended a Women, Infant and Children (WIC) program at a local county public health clinic and compare the incidence of smoking behaviors of pregnant Arab American women with pregnant women who were not Arab Americans.

DESIGN AND METHODS

Data were extracted from a computer database that contained information from health history charts of pregnant Arab and non-Arab American women. The study sample was 830 women, 823 of whom were Arab American participants enrolled in the WIC program in Michigan.

RESULTS

Approximately 6% of pregnant Arab Americans smoked during pregnancy. The prevalence of smoking behavior among pregnant Arab American women was similar to that of smoking behaviors of Hispanics and Asian Americans in the United States.

CONCLUSION

Although smoking behavior is a serious problem among Arab American immigrants in general and in the Arab world in particular, cultural factors that support healthy behavior during pregnancy in the Arab culture seem to limit the use of tobacco in pregnant women. Nurses who care for Arab American pregnant women can use this information to better inform their care of these patients.

Comparison of cigarette and water-pipe smoking by Arab and non-Arab-American youth

BACKGROUND

Water-pipe smoking is a rapidly growing form of tobacco use worldwide. Building on an earlier report of experimentation with cigarette and water-pipe smoking in a U.S. community sample of Arab-American youth aged 14-18 years, this article examines water-pipe smoking in more detail (e.g., smoking history, belief in harmfulness compared to cigarettes, family members in home who smoke water pipes) and compares the water-pipe-smoking behaviors of Arab-American youth with non-Arab-American youth in the same community.

METHODS

A convenience sample of 1872 Arab-American and non-Arab-American high school students from the Midwest completed a 24-item tobacco survey. Data were collected in 2004-2005 and analyzed in 2007-2008.

RESULTS

Arab-American youth reported lower percentages of ever cigarette smoking (20% vs 39%); current cigarette smoking (7% vs 22%); and regular cigarette smoking (3% vs 15%) than non-Arab-American youth. In contrast, Arab-American youth reported significantly higher percentages of ever water-pipe smoking (38% vs 21%) and current water-pipe smoking (17% vs 11%) than non-Arab-American youth. Seventy-seven percent perceived water-pipe smoking to be as harmful as or more harmful than cigarette smoking. Logistic regression showed that youth were 11.0 times more likely to be currently smoking cigarettes if they currently smoked water pipes. Youth were also 11.0 times more likely to be current water-pipe smokers if they currently smoked cigarettes. If one or more family members smoked water pipes in the home, youth were 6.3 times more likely to be current water-pipe smokers. The effects of ethnicity were reduced as a result of the explanatory value of family smoking.

CONCLUSIONS

Further research is needed to determine the percentages, patterns, and health risks of water-pipe smoking and its relationship to cigarette smoking among all youth. Additionally, youth tobacco prevention/cessation programs need to focus attention on water-pipe smoking in order to further dispel the myth that water-pipe smoking is a safe alternative to cigarette smoking.

Demographic and psychosocial characteristics of smokers and nonsmokers in low-socioeconomic status rural Appalachian 2-parent families in Southern West Virginia

CONTEXT

Rural Appalachian women living in poverty have a high prevalence of prenatal smoking; yet, few studies have examined this issue.

PURPOSE

To investigate the demographic and psychosocial characteristics of prenatal smokers and nonsmokers in low-socioeconomic status, rural Appalachian 2-parent families.

METHODS

During an 18-month period, two thirds of eligible low-socioeconomic status prenatal patients were recruited for a longitudinal study from a community health clinic in a rural West Virginia county. Data for the present report are from 92 women with a husband/partner (37 smokers and 55 nonsmokers) who completed a prenatal interview in the last trimester of pregnancy. This interview included demographics, personality traits, self-esteem problems, social support, and marital/partner relationship.

FINDINGS

Compared to nonsmokers, prenatal smokers were less likely to have completed high school, less extroverted, and also had lower self-esteem, less intimate support, and more negative marital relationship.

CONCLUSIONS

High school graduation and variables related to positive personality and supportive relationships distinguished smokers from nonsmokers. The causal relationship between these variables and prenatal smoking requires more work in larger and varied populations, and this study provides some direction for ongoing longitudinal investigation.

Water-pipe (narghile) smoking: an emerging health risk behavior

Narghile, or water-pipe smoking (WPS), has been practiced extensively for approximately 400 years. It is common in the Arabian Peninsula, Turkey, India, Pakistan, and other countries. In recent years, there has been a revival of WPS, notably among youth. Most US health professionals are unfamiliar with the practice and health consequences of WPS. Therefore, this trend presents a new challenge for adolescent health care providers. The composition of the tobacco used in WPS is variable and not well standardized. Studies that have examined narghile smokers and the aerosol of narghile smoke have reported high concentrations of carbon monoxide, nicotine, "tar," and heavy metals. These concentrations were as high or higher than those among cigarette smokers. The few scientific data regarding the adverse health consequences of WPS point to dangers that are similar to those associated with cigarette smoking: malignancy, impaired pulmonary function, low birth weight, and others. Additional dangers not encountered with cigarette smoking are infectious diseases resulting from pipe sharing and the frequent addition of alcohol or psychoactive drugs to the tobacco. Public health strategies for controlling the emerging epidemic of WPS include carrying out epidemiologic and toxicologic research; implementation of laws to limit acquisition and use; and health education, targeting adolescents in particular.

Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers

BACKGROUND

To compare patterns of use, beliefs, and attitudes related to waterpipe smoking between university students (beginning smokers) and cafe customers (established smokers) in Aleppo Syria, in order to explore the evolution of this smoking method.

METHODS

Two cross-sectional surveys were conducted among representative samples of university students (total 587, 48.4% men, mean age 22 years), and waterpipe users among cafe' customers (total 268, 60% men, mean age 30 years) in Aleppo, Syria. We used interviewer-administered questionnaire inquiring about pattern of waterpipe smoking (initiation, frequency), situational characteristics of use (partner, place, sharing), beliefs related to waterpipe smoking (harmful/addictive properties of waterpipe), attitudes related to waterpipe smoking (confidence in quitting, will to quit, motivation for quitting, past year quit attempt), and cigarette smoking.

RESULTS

Daily and regular patterns of smoking become more prevalent with increased duration of smoking, but intermittent smoking remains the predominant pattern of waterpipe use. Women seem to be drawn later to the habit, which seem to escape the usual taboo against women's cigarette smoking. Patterns and context of waterpipe use tend to change with progress of the practice affecting frequency, setting, and sharing of waterpipe. Unlike beginners, established waterpipe smokers seem more smoking-method oriented, more hooked on the habit, less willing to quit, and less likely to foresee challenges to quitting.

CONCLUSION

Use patterns and attitudes related to waterpipe smoking evolve to accommodate the change in dependence and life circumstances of the smoker. Most of use features, beliefs, attitudes, as well as time-course seem unique to this smoking method requiring novel approach to intervention.

Are waterpipe users interested in quitting?

Waterpipe smoking has increased dramatically worldwide in recent years, with an estimated 100 million daily users. Research on this traditional Middle Eastern tobacco use method is in its infancy, and little is known about users' cessation-related attitudes and experiences. A random sample of 268 narghile (waterpipe) smokers (40% female; mean age = 30 years; range = 18-68) was obtained from cafes and restaurants in Aleppo, Syria. The majority of users (86.5%) believed they could quit using waterpipes at any time, but that belief was inversely related to perceived dependence, with only 48.7% of those who thought they were "very hooked" believing they could quit. Interest in quitting was expressed by 28.4% of subjects, with the majority (89.2%) reporting health concerns as a primary reason, and 59.2% having made an unsuccessful quit attempt in the past year. In a logistic regression model, independent predictors of interest in quitting included being married, having smoked for fewer years, not increasing the frequency of smoking over time, and having family members who do not smoke a waterpipe and disapprove of its use. Results indicate that a sizable percentage of waterpipe users express interest in quitting and have tried unsuccessfully in the past to quit. Waterpipe use needs to be considered in developing effective tobacco use cessation programs in the Middle East.

Beliefs and attitudes related to narghile (waterpipe) smoking among university students in Syria

PURPOSE

To assess the beliefs and attitudes related to narghile (waterpipe) smoking that are likely to contribute to its increased popularity among young people in Syria.

METHODS

In 2003, a cross-sectional survey was administered to university students in Aleppo, using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 +/- 2.1; response rate 98.8%).

RESULTS

The most common positive perceptions of narghile were related to its smell and taste. Negative perceptions of narghile included the smoke produced, the pollution, and perceived adverse health effects. Students believed the popularity of narghile to be part of a rising regional trend in its use, due to its being an appealing way to spend leisure time socializing with friends. More students (49.7%) believed narghile to be more harmful to health than cigarettes, compared with 30% who believed the opposite. Respiratory disease was the most commonly cited health effect of narghile smoking. Family attitudes regarding tobacco use by younger members were more permissive about narghile compared with cigarettes, and, surprisingly, were more permissive about females smoking narghile than males doing so.

CONCLUSIONS

The rise in narghile smoking as a trendy social habit appears to be occurring despite considerable appreciation of its potential health risks. Permissiveness of adult family members towards narghile use by young female members, especially in the presence of a strong taboo against female cigarette smoking may contribute to the continuous spread of narghile smoking among women in Syria.

Consumo de tabaco durante el embarazo en España: análisis por años, comunidades autónomas y características maternas

BACKGROUND AND OBJECTIVE

The information about the convenience of non-smoking during pregnancy has increased in recent years. For this reason, we studied weather there has been any variation in smoking habits by pregnant women in Spain.

SUBJECTS AND METHOD

We used data from 31,056 mothers of infants without congenital defects, from all the Spanish Autonomic Regions. These data had been collected with the same methodology all over the country. The evolution of maternal smoking habit was analyzed by years, Autonomic Regions and maternal characteristics.

RESULTS

During the last years of the study (1995-2002), 30.31% of mothers smoked during pregnancy, with variations among different ethnic groups. It was observed a secular increase in the prevalence of smoker mothers from 1978 to 1991, which was further stable in about 27-28%. There was no secular decrease in the analyses by maternal age, number of cigarettes, and Autonomic Regions. Only smoker mothers with higher educational levels diminished smoking in 1993, with it being stable in about 23%. Mothers younger than 25 years were the heaviest smokers in all the years of the study. We confirmed a close relationship between tobacco, alcohol and illegal drugs consumption.

CONCLUSIONS

Our data indicate that the prevalence of women smoking during pregnancy has not diminished over the years or by Autonomic Regions, although 19.19% of smoker pregnant women quit smoking during the first months of pregnancy. Moreover, the heaviest smoker mothers were the youngest ones in all the years of the study. These results show the need to increase the information for women so that they quit smoking before pregnancy.

Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon

BACKGROUND

Currently, little is known about argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in the Arab world, despite emerging evidence on the adverse health effects of argileh smoking and well-established knowledge about the health risks of cigarette smoking during pregnancy.

OBJECTIVES

The present study assesses pregnant Arab women's knowledge of chemical contents and related harmful effects of argileh and cigarettes, their attitudes towards smoking argileh and cigarettes, and their actual smoking of argileh and cigarettes, both before and during pregnancy.

METHODS

A stratified sample of 864 women from 23 health care centers in Lebanon completed a structured, interviewer-administered questionnaire. Information was collected on basic demographic variables, women's knowledge, attitudes, and cigarette and argileh smoking.

RESULTS

Women were partially knowledgeable about the health risks of cigarette smoking, knew little about the harmful ingredients of argileh smoking, and had many misconceptions regarding how argileh worked or how it can produce harm. Attitudes were permissive towards all forms of smoking. Almost one quarter (23%) of participants reported smoking during pregnancy, with 17% smoking only cigarettes, 4% smoking only argileh, and 1.5% smoking both cigarette and argileh.

CONCLUSION

A significant and growing percentage of pregnant Arab women are smoking in Lebanon, with four cigarette smokers for every argileh smoker. Smoking behaviors are empirically linked with important gaps in knowledge and with permissive attitudes. These data may be used to design more effective prevention programs targeting this vulnerable population.

Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic

CONTEXT

The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Current research, treatment, and policy efforts focus on cigarettes, while many people in developing regions (Asia, Indian subcontinent, Eastern Mediterranean) smoke tobacco using waterpipes. Waterpipes are increasing in popularity, and more must be learned about them so that we can understand their effects on public health, curtail their spread, and help their users quit.

OBJECTIVE

To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy.

DATA SOURCES

A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used.

STUDY SELECTION

Every identified published study related to waterpipe use was included.

DATA SYNTHESIS

Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications.

CONCLUSIONS

More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.

Factors related to frequency of narghile (waterpipe) use: the first insights on tobacco dependence in narghile users

AIMS

To evaluate factors related to level of narghile (waterpipe) use as a first step towards modeling tobacco dependence among narghile users.

DESIGN

Cross sectional survey done in 2003 using interviewer-administered anonymous questionnaires.

SETTING

Cafes/restaurants serving narghiles in Aleppo, Syria.

PARTICIPANTS

Narghile smokers (161 men and 107 women; mean age, 30.1 +/- 10.2, 161; age range, 18-68 years; response rate, 95.3%) randomly selected from the 17 cafes/restaurants sampled.

MEASUREMENTS

Frequency of narghile use (daily, weekly, monthly) was assessed as a function of several factors potentially indicative of dependence, including situational characteristics (where, when, and with whom smoking occurs; seasonality of use, and sharing of narghile), attitudes, and experience with quitting narghile use, escalation of use over time, future intentions regarding use, perception of being "hooked" on narghile, and cognitions/behaviors engaged in to support use (carrying one's own narghile; think of narghile when it is not available; considering narghile for selection of cafes/restaurants).

FINDINGS

Frequency of narghile use was strongly correlated with participant's subjective judgment of how hooked they are on narghile (coefficient, 0.5). Predictors of narghile use frequency according to multinomial logistic regression were: male gender, smoking mainly alone versus with others; smoking mainly at home versus outside; smoking more frequently since initiation, being hooked on narghile, carrying narghile, and considering it for cafe/restaurant choice.

CONCLUSIONS

Our data reveal two main domains of a tobacco dependence syndrome likely to be relevant to narghile; the first reflects the effects of nicotine contained in narghile tobacco, and is not very different from what is seen with other tobacco products, and the second is unique to narghile and is related mainly to its social dimension, with more intensive smokers showing an increasingly individual pattern of narghile smoking.

Estimating the beginning of the waterpipe epidemic in Syria

Background

Waterpipe smoking is becoming a global public health problem, especially in the Eastern Mediterranean region (EMR).

Methods

We try in this study, which is a cross sectional survey among a representative sample of waterpipe smokers in cafes/restaurants in Aleppo-Syria, to assess the time period for the beginning of this new smoking hype. We recruited 268 waterpipe smokers (161 men, 107 women; mean age ± standard deviation (SD) 30.1 ± 10.2, response rate 95.3%). Participants were divided into 4 birth cohorts (≤ 1960, 1961–1970, 1971–1980, >1980) and year of initiation of waterpipe smoking and daily cigarette smoking were plotted according to these birth cohorts.

Results

Data indicate that unlike initiation of cigarette smoking, which shows a clear age-related pattern, the nineties was the starting point for most of waterpipe smoking implicating this time period for the beginning of the waterpipe epidemic in Syria.

Conclusion

The introduction of new flavored and aromatic waterpipe tobacco (Maassel), and the proliferation of satellite and electronic media during the nineties may have helped spread the new hype all over the Arab World.